In a multivariate analysis, starting treatment very early in the onset of disease — less than 12 weeks' duration — more than doubled the likelihood of remission at 1 year, according to Gianfranco Ferraccioli, MD, of Catholic University of the Sacred Heart in Rome, and colleagues.

A second predictor of remission was starting a disease-modifying anti-rheumatic drug (DMARD) within the first 3 months, the researchers reported in the June Annals of the Rheumatic Diseases.

"The take-home message that arises remains: diagnose early and treat to target within 12 weeks from symptom onset," Ferraccioli and colleagues stated.

Evidence has been growing during the last decade from clinical trials showing that major differences in clinical outcome can result when treatment for rheumatoid arthritis begins promptly and is targeted to specific goals such as decreasing the disease activity score in 28 joints (DAS28) below 2.6.

To explore these observations in a real-world setting, Ferraccioli's group enrolled 1,795 patients with symptomatic arthritis of less than 1 year's duration from three Italian referral clinics between 2007 and 2009.

The initial diagnosis was rheumatoid arthritis in 39.6 percent of patients, the researchers found.

Among the remainder, diagnoses included undifferentiated arthritis in 50.7 percent, psoriatic arthritis in 20.7 percent, spondyloentesoarthritis in 10.6 percent, and small numbers of other disorders such as reactive arthritis and polymyalgia rheumatica.

Disease duration was less than 3 months in 148 patients.

All participants began treatment with methotrexate at a dosage of 15 mg per week, which could be increased to 25 mg per week if needed.

If patients continued to have active disease at 3 months, the treating physician could prescribe an additional DMARD or a tumor necrosis factor (TNF) inhibitor, and the three centers followed their own treatment protocols.

Three-quarters of the 711 patients with an initial diagnosis of rheumatoid arthritis were women, and mean age was 55.

A total of 481 had moderate-to-high disease activity, as determined by a DAS28 score above 3.2, and were included in the analysis.

Remission according to the DAS28 criteria was reached by 34.3 percent of patients by 12 months.

That number was somewhat lower than in some recent clinical trials such as FIN-RACo and TICORA, the researchers pointed out.

"It should be considered, however, that all these studies were randomized, controlled trials and included established treatment protocols, while our study, being an observational study with broad individual autonomy in the choice of therapeutic regimen, may better reflect what happens in the real world of clinical practice," they observed.

At 1 year, 68.4 percent of the 481 patients with moderate-to-high disease activity were receiving only conventional DMARDs, while the remaining 31.6 percent were taking a TNF inhibitor.

Among patients with disease duration longer than 3 months at baseline, 74.4 percent were on DMARDs and 25.6 percent were on a biologic.

In contrast, among patients with very early disease at baseline, 90.5 percent were taking only conventional DMARDs, while 9.5 percent were on a TNF inhibitor.

And in the group of patients who were in remission at 1 year, only 10 percent of those with early disease at baseline were on TNF inhibitors, compared with 32.2 percent of those with longer disease duration.

Baseline scores on the Health Assessment Questionnaire (HAQ), which measures disability, were 1.2 in the overall cohort, decreasing to 0.5 at 1 year.

HAQ scores below 0.5, indicating no disability, were achieved by 62.7 percent of the very-early disease group compared with 41.3 percent of those with longer baseline disease duration.

Treatment of very early disease is likely to result in considerable economic benefit because of the decreased use of biologic treatment, the researchers noted.

"As it has been established that the annual [rheumatoid arthritis] costs have increased to 20,000 euros [$25,750] with a HAQ increase from 0.5 to 2, and that decreasing HAQ from 1.5 to 0.5 means a gain of at least US $4,385 per year, the significant decrease in HAQ values obtained with an early intervention ... appears to be cost saving," they stated.

The findings of this study support the recommendation by the European League Against Rheumatism that individuals who present with arthritis in more than one joint should be referred to a rheumatologist, preferably within 6 weeks of symptom onset, Ferraccioli's group concluded.

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